Pete Stark

Mr. STARK

Mr. STARK. I just wanted to correct the misstatements of the previous speaker. On March 8 the committee report indicates that the gentleman from Florida [Mr. Gibbons] did not vote. As a practical matter, he was out sick on that day and did not vote on this bill either way. Second, the House of Representatives has never considered Medicare select in its deliberations. It was added about the Senators in a conference and never considered in the House of Representatives, and I stand by the statement that there are no Federal regulations covering it.

Mr. STARK. Mr. Speaker, will the gentleman yield?

Mr. STARK. If I can reclaim and explain to the gentleman. The premiums under the current law cannot be raised during the middle of the year so that there, first, is no danger that existing beneficiaries under these plans would have their premiums raised until the end of their policy year; and, second, there would be no restrictions on their being able to maintain their policies. It is just that the salesmen, admittedly, and it may hurt the insurance salesmen because they earn their living doing this. I would just suggest that it is risky business dealing with the fragile elderly who are easily confused, and I say that Democrat elderly are as confused as Republican elderly. We ought to be able to protect them through the process.

Mr. STARK. Mr. Speaker, the gentlewoman from Ohio is correct. I am sure we are not making many friends with all this, but this is one of the things we might do to accommodate many of our colleagues who might like to end the 100 days sooner: Is there any reason in the rule that the bill could not be considered this afternoon?

Mr. STARK. I yield to the gentlewoman from Ohio.

Mr. STARK. Mr. Speaker, may I engage the gentlewoman from Ohio [Ms. Pryce] in a colloquy for a moment. Mr. Speaker, I gather that the majority feels that we should move ahead rapidly with this bill, and I begin to sense that we are not going to have any opportunity to amend it.

Mr. STARK. I yield to the gentlewoman from Ohio.

Mr. STARK. I yield to the gentleman from California.

Mr. STARK

Mr. STARK. Mr. Speaker, today I am introducing the Medicare Mental Health Improvement Act of 1995. This bill will improve the mental health services available to Medicare beneficiaries. It represents an urgently needed change in benefits to reflect contemporary methods of providing mental health care and prevent unnecessary hospitalizations. The bill expands Medicare Part A and Part B mental health and substance abuse benefits to include a wider array of settings in which services may be delivered. It eliminates the current bias in the law toward delivering services in general hospitals. It permits services to be delivered in a variety of residential and community-based settings. Through use of residential and community-based services, costly inpatient hospitalization can be avoided. Services can be delivered in the setting most appropriate to the individual's needs. In 1991, as a nation we spent approximately $58 billion for treatment of mental illness and another $17 billion for substance abuse disorders. Medicare expenditures in these areas for 1993 were estimated at $3.6 billion or 2.7 percent of Medicare's total spending. Over 80 percent of that cost was for inpatient hospitalization. In addition to these direct medical costs there are also enormous social costs resulting from these disorders. It has been estimated that severe mental illness and substance abuse disorders cost $78 billion per year in lost productivity, lost earnings due to illness or premature death, and costs for criminal justice, welfare and family care giving. Mental disorders affect about 22 percent of the adult population in a 1 year period; 2 to 3 percent of the population experience severe mental illness or substance abuse disorders. This population is very diverse. Some people experience problems of recent origin that never recur, given appropriate treatment. Others have severe problems that persist for a long period of time. Mental illness and substance abuse disorders include many different diagnoses, levels of disability and duration of disability. Therefore, the people affected have many different needs. Diagnosis and treatment of mental illness and substance abuse have changed dramatically since the Medicare benefit was designed. No longer are treatment options limited to large public psychiatric hospitals. The great majority of people can be treated on an outpatient basis, recover quickly and return to productive lives. Even those who once would have been banished to the back wards of large institutions can now live successfully in the community. In recent years, the range of settings for care has diversified and providers have become more specialized. Treatments are more numerous and more effective than ever before. Treatment for mental disorders is in many cases just as effective as treatment for many physical disorders. For many people, however, appropriate treatment is inaccessible because they lack adequate insurance coverage. Medicare benefits have not kept pace with advancements in the field of mental health. This bill would permit Medicare to pay for a number of intensive community-based services. In addition to outpatient psychotherapy and partial hospitalization that are already covered, beneficiaries would also have access to psychiatric rehabilitation, ambulatory detoxification, in-home services day treatment for substance abuse and day treatment for children under age 19. In these programs, people can remain in their own homes while receiving services. These programs provide the structure and assistance that people need to function on a daily basis and return to productive lives. They do so at a cost that is much less than inpatient hospitalization. For example, the National Institute for Mental Health in 1993 estimated that the cost of inpatient treatment for schizophrenia can run as high as $700 per day, including medication. The average daily cost of partial hospitalization in a community mental health center is only about $90 per day. When community-based services are provided, inpatient hospitalizations will be less frequent and stays will be shorter. In many cases hospitalizations will be prevented altogether. This bill will also make care management available for those with severe mental illness or substance abuse disorders. People with severe disorders often need help managing many aspects of their lives. Case management assists people with severe disorders by making referrals to appropriate providers and monitoring the services received to make sure they are coordinated and meeting the beneficiaries' needs. Case managers can also help beneficiaries in areas such as obtaining a job, housing, or legal assistance. When services are coordinated through a case manager, the chances of successful treatment are improved. For those who cannot be treated while living in their own homes, this bill will make several residential treatment alternatives available. These alternatives include residential detoxification centers, crisis residential programs, therapeutic family or group treatment homes and residential centers for substance abuse. Clinicians will no longer be limited to sending their patients to inpatient hospitals. Treatment can be provided in the specialized setting best suited to addressing the person's specific problem. Inpatient hospitalization, of course, will remain an important avenue of treatment for some beneficiaries. Currently, the law contains a bias toward providing inpatient services in general hospitals. That bias results from the payment differences between psychiatric hospitals and general hospitals. Right now in psychiatric hospitals, benefits may be paid for 190 days in a person's lifetime. This limit was established primarily in order to contain Federal costs. In fact, CBO estimates that only about 1.6 percent of Medicare enrollees hospitalized for mental disorders or substance abuse used more than 190 days of service over a 5-year period. In general hospitals, benefits are available for 90 days in a benefit period and a person may have numerous benefit periods throughout his or her lifetime. This can result in people who have almost used up their 190 lifetime days in a psychiatric hospital being forced to receive services in a general hospital. They are also shunted into nursing homes. A recent study found that, among nursing home residents who did not have a cognitive impairment, such as Alzheimer's disease, 13 percent exhibit mental disorders. While some general hospitals and nursing homes are up to this task, others are ill-equipped to meet the needs of people with severe mental illness or substance abuse problems. Under the provisions of this bill, beneficiaries who need inpatient hospitalization can be admitted to the type of hospital that can best provide treatment for his or her needs. Inpatient hospitalizations would be covered for up to 60 days per year. The average length of hospital stay in 1992 for an adult was 16 days and for an adolescent was 24 days. The 60 day limit, therefore, would adequately cover inpatient hospitalization for the vast majority of Medicare beneficiaries, while still providing some modest cost containment. Restructuring the benefit in this manner will level the playing field for psychiatric and general hospitals. The bill I am introducing today is an important step toward providing comprehensive coverage for mental health. Timely treatment in appropriate settings will lessen health costs in the long run. It will also lessen the social costs of crime, welfare, and lost productivity to society. This bill will assure that the mental health needs of Medicare beneficiaries are no longer ignored. I urge my colleagues to join me in support of this bill. A summary of the bill follows: in general The bill revises the current mental health benefits available under Medicare to de-emphasize inpatient hospitalization and to include an array of intensive residential and intensive community based services. part a provisions The bill permits benefits to be paid for 60 days per year for inpatient hospital services furnished primarily for the diagnosis or treatment of mental illness or substance abuse. The benefit is the same in both psychiatric and general hospitals. The following ``intensive residential services'' are covered for up to 120 days per year: Residential detoxification centers; crisis residential or mental illness treatment programs; therapeutic family or group treatment home; and residential centers for substance abuse. Additional days to complete treatment in an intensive residential setting may be used from inpatient hospital days, as long as 15 days are retained for inpatient hospitalization. The cost of providing the additional days of service, however, could not exceed the actuarial value of days of inpatient services. A facility must be legally authorized under State law to provide intensive residential services or be accredited by an accreditation organization approved by the Secretary in consultation with the State. A facility must meet other requirements the Secretary may impose to assure quality of services. Services must be furnished in accordance with standards established by the Secretary for management of the services. Payment for intensive residential services would be the lesser of reasonable cost under 1816(v) or customary charges less the amount the provider may charge under 1866(a)(2)(A). Inpatient hospitalization and intensive residential services would be subject to the same for physical disorders. part b provisions Outpatient psychotherapy for children and the initial 5 outpatient visits for treatment of mental illness or substance abuse of an individual over age 18 have a 20-percent copayment. Subsequent therapy for adults would remain subject to the 50 percent copayment. The following intensive community-based services are available for 90 days per year with a 20-percent copayment (except as noted below): Partial hospitalization; psychiatric rehabilitation; day treatment for substance abuse; day treatment under age 19; in home services; case management; and ambulatory detoxification. Case management would be available with no copayment and for unlimited duration for ``an adult with serious mental illness, a child with a serious emotional disturbance, or an adult or child with a serious substance abuse disorder (as determined in accordance with criteria established by the Secretary).'' Day treatment for children under age 19 would be available for up to 180 days per year. Additional days of service to complete treatment can be used from intensive residential days. The cost of providing the additional days of service, however, could not exceed the actuarial value of days of intensive residential services. A non-physician mental health or substance abuse professional is permitted to supervise the individualized plan of treatment to the extent permitted under State law. A physician remains responsible for the establishment and periodic review of the plan of treatment. Any program furnishing these services (whether facility-based or freestanding) must be legally authorized under State law or accredited by an accreditation organization approved by the Secretary in consultation with the State. They must meet standards established by the Secretary for the management of such services.

Mr. STARK

Mr. STARK. Mr. Chairman, I would like first to congratulate the distinguished gentlewoman from Connecticut, the sponsor of H.R. 483. While I may agree with what is in the bill, it is the absence of a few things with which she and I would differ. But she gets my highest admiration for tenacity. She has done an excellent job in bringing this bill to the floor promptly. I do believe that there is a need for strong beneficiary protections. These may be prophylactic. They may be only a safety net, but we have had anecdotal evidence of abuses. And this program is new, and the administration had hoped that we would only extend it for 18 months. Many of us feel that Federal standards, which would be enforced or reinforced by States, would be in order. The few States that choose not, like my own State of California, to regulate this through the insurance code, might be required to. Had we had the opportunity, and we will have a partial opportunity in the substitute to be offered by the distinguished gentleman from California later in the proceedings, I would have suggested that we perhaps extend this for 5 years; also, that we have Federal oversight of Medicare select. The amendment that I would offer perhaps would require Medicare select plans to have similar requirements as we now require for Medicare approved HMO's, called risk contractors. Those would include community rating. For example, in California, to compare identical plans with Prudential, AARP's plan, and Blue Cross, the only offeror of Medicare select, there is, indeed, a savings for the first 4 years. From 1965 to 1969, Medicare select only costs $780. AARP's Prudential plan is $957, but it is $957 until you expire or stop paying your premiums. The Medicare select plan jumps to $1,080 at age 70, $1,260 at 75 and, over 80, it is $1,380, almost a 40 percent increase. This, I believe, is improper and impacts most on seniors when they can lest afford to pay those premiums. I think we should consider the idea of forbidding premiums that are age-related. We should have State certification of these plans and an amendment to define the benefit package, not so as to limit it, but so as to put it into context with the plans that are now offered under MediGap so that seniors will have the opportunity to use free market choice and pick a plan that is, in fact, one that they can compare on a price basis. Many of these amendments will be in the substitute offered by the gentleman from California [Mr. Waxman]. I would urge that that be supported. I think that we will revisit this. One of the reasons I do not want to belabor this, and I will in a moment yield back my time, is that my guess is that some of these provisions may be added later in the legislative process. I hope then we can consider them at some more deliberate pace and consider which of these amendments will make Medicare select a better product, more consumer friendly than what might appear without the regulations that are missing from the current bill. I thank the distinguished gentleman for yielding time to me.

Mr. STARK

Mr. STARK. Mr. Speaker, just 100 years ago this year, a German physicist, Wilhelm Conrad Roentgen, discovered x rays. Within weeks, American scientists, physicians, and industrialists were making new discoveries with x rays and were putting them to work in medicine and industry. No major scientific discovery ever spread so fast or found such instant acceptance in many areas of life. At first physicians peered at dim images to perceive bullets, bones, and kidney stones. Equipment and technique were improved. Soon physicians could look for other health problems with x rays. They learned that x rays could be used to cure some diseases, particularly forms of cancer. A medical specialty, radiology, grew among the men and women who applied x rays in health care. Over the century, radiologists added to their competence with the products of scientific breakthroughs. From the atomic bomb research came radioisotopes, so vital for diagnosing body organ function and treating cancers. From radar and sonar came medical applications of ultrasound. From the space efforts came the ability to analyze images electronically, bounce them off of satellites, and store them for instant recall. From computers came computed tomography and magnetic resonance imaging. The million-volt energies of linear accelerators allow radiation oncologists to deliver pinpoint treatment of cancers. This year, two-thirds of all Americans will receive a medical diagnostic imaging procedure. Two-thirds of those with cancers will receive radiation as part of their treatment. In a hundred years, radiology has become a vital part of our health care pattern. During this year, more than 100 professional societies and companies which supply the family of radiology have organized Radiology Centennial, Inc. to conduct a year-long series of celebratory events. Among these events is a special convocation on April 30 here in Washington. Mr. Speaker, I ask that the record show that this House joins other Americans in recognizing the value of radiology to all of us in this, its 100th year.

Mr. STARK

Mr. STARK. Mr. Speaker, I rise today to recognize Dr. J. Alfred Smith, Sr., pastor of the 4,000 member Allen Temple Baptist Church in Oakland, California. Dr. Smith will be honored this week by the Baptist Ministers Union of Oakland and Vicinity for being a good neighbor to the citizens of Oakland. Dr. Smith is Professor of Preaching and Christian Ministry at the American Baptist Seminary of the West and has been Pastor at Allen Temple for over 25 years. Dr. Smith holds the Th.M. degree and was granted a Doctor of Humane Letters (Honoris Causa) in 1990 from the American Baptist Seminary of the West. He also holds the D. Min. degree from the Golden Gate Theological Seminary. He is currently president of the Baptist Ministers Union. Dr. Smith has been the recipient of many awards and commendations. He has served as President of the Progressive National Baptist Convention and the American Baptist Churches of the West. He has lectured at most of the major universities in America, including Yale, Harvard, Duke, and Stanford. He was recently listed by Ebony magazine as one of the greatest African American preachers in the United States. He was also recently named by the Oakland Tribune as ``Outstanding Citizen of the Year''. Dr. Smith has long been a leader in our community. As the Baptist Ministers Union has stated, he has moved beyond his pulpit into our communities to respond with love to the needs of all persons, irrespective of color, class, creed, gender, or sexual orientation. That is why I am proud to recognize him today. He is more than a ``good neighbor''--he is the best neighbor!

Mr. STARK

Mr. STARK. Mr. Speaker, Federal action is needed in order to preserve the letter and intent of Congress' Height of Buildings Act of 1910. In introducing this legislation, I have no intention of interfering with the district's zoning decisions, only to enforce Federal law. I do not relish having to take this action, but it is out of a necessity generated by the desire of some to circumvent Federal law. This legislation will simply enforce current law regulating the height of buildings constructed in the District of Columbia by prohibiting the District of Columbia from issuing any building or occupancy permit for a project located at 1328 G Street Northwest unless the project to be developed complies with the required building height limitation of 110 feet. In order to get around the law, the developers of this project have argued against not only Federal law, but the laws of physics. No matter how much a developer might wish it to be so, a property cannot be in two places at the same time. The plot of land in question is located in the middle of the 1300 block of G Street. Nonetheless, the developers claim that it actually ``fronts'' on 13th Street. As found by the National Trust for Historic Preservation, ``that is not the case here--1328 G Street is clearly a mid-block building separated from 13th Street by 75 feet, two lots, and a public alley. Any suggestion that 1328 G Street `fronts' on 13th Street is clearly an artifice, and would circumvent the requirements of the Building Height Act.'' I am submitting for the Record a letter from the National Trust for Historic Preservation to the National Capital Planning Commission providing greater detail of the developer's shenanigans with this project. Again, taking this action is not something that I relish, but it is necessary. It is necessary in order to enforce existing law, to protect the Federal interest, and to preserve the unique skyline of the Nation's Capital. National Trust for Historic Preservation, Washington, DC, March 16, 1995. Re closing of a public alley and establishment of an easement in square bounded by F, 13th, G, and 14th Streets, N.W. (D.C. Council Act 10-295). Hon. Thomas M. Davis III, Chairman, District of Columbia Subcommittee, House Government Reform and Oversight Committee, Washington,

Mr. STARK

Mr. STARK. Mr. Speaker, Edward Roberts, a highly acclaimed activist for the rights of persons with disabilities and a personal friend, died March 14 of cardiac arrest at his home in Berkeley, CA. Mr. Roberts was a tireless fighter for the rights of the disabled, even though he himself was severely disabled. At the age of 14, Edward Roberts became paralyzed from the neck down as a result of polio. Although this paralysis would dramatically change his life, Mr. Roberts found the courage to not only exist, but to excel. He became infuriated when a counselor informed him he would never work because of his disability. Ironically, Mr. Roberts later became the supervisor of that same counselor. A driving force in Edward Roberts life was his love of a challenge. Being able to move only one finger, Mr. Roberts was one of the first disabled individuals to attend the University of California at Berkeley. While attending college, he and a group of his fellow classmates organized a counseling program for persons with disabilities. This innovative program was named ``Rolling Quads''. After graduation, Mr. Roberts continued his fight to enhance the lives of those who had disabilities. In 1972, he cofounded the Center for Independent Living. This program won acclaim for the incredible work it accomplished and for the fact that it was the first organization run by and for persons with disabilities. This program was an inspiration to people around the Nation. It spawned 400 similar institutions throughout the United States. In 1975, Gov. Jerry Brown appointed Edward Roberts to head the State Department of Rehabilitation. He utilized the organization's 2,500 employees and its $140 million budget to implement programs that promoted self-reliance for those with disabilities. Mr. Roberts ran this organization until 1983, at which time he founded the World Institute on Disability [WID]. This think tank is involved in creating and monitoring programs that help individuals with disabilities. Over his 56 years, Edward Roberts positively impacted a countless number of lives. Deborah Kaplan, the president of the WID Program and a disability rights lawyer, said ``There are literally thousands of people whose lives have been influenced by Ed.'' Through his leadership skills as well as his intense drive to overcome discrimination, Mr. Roberts was a great role model for those with and without disabilities. Friends as well as colleagues will morn this immense loss.

Mr. STARK

Mr. STARK. Mr. Speaker, Mr. T.J. Rodgers, the CEO of Cypress Semiconductor located in San Jose, CA, wrote the following memo for the Red Herring magazine, January 1995 issue. He makes some excellent points: Government megascience programs all too often become the grossest of pork projects. Keep it small, keep it simple, keep it seed money for merit-based research is his message. It is a message worth heeding. The article follows: Cypress Semiconductor January 9, 1994. To: The Congress of the United States of America. From: T.J. Rodgers, CEO of Cypress Semiconductor. Re: Cut the Techno-Pork! My advice to the new Congress on technology policy is to kill government science megaprograms, get out of the technology-subsidy business, and double science and technology funding for universities through thousands of small grants. These priorities are particularly important for Republicans who find big-science wonders hard to resist. With the possible exception of the Manhattan Project, government science megaprograms have a terrible record of return on the taxpayers' investment. Remember synfuels? This scheme to create gasoline from coal followed the classic, eight-step scenario for wasteful government megaprograms: (1) Scare the hell out of them. (What happens when the oil cartel shuts off the gasoline?) (2) Declare that the program is so big, only the government can pull it off. (Translation: No other sucker could be convinced to invest in this loser.) (3) Get expert advice. (Translation: Listen to oil industry lobbyists who are paid to know that what is good for the oil industry is good for America.) (4) Create a consensus. (Translation: Spread the pork out to enough states to get the bill passed.) (5) Execute. (Translation: Use government funds to hire a large P.R. staff.) (6) Fail. (7) Lose $88 billion. (8) Blame the Republicans for underfunding the project. Remember the superconducting supercollider (SSC)? I debated a particle physicist from the University of Texas-Arlington on National Public Radio on its merits. He claimed that $12 billion was a cheap price to discover the sixth and elusive ``top quark'' subatomic particle. I argued that the genius of the physics community would find a cheaper way to float the top quark in electric and magnetic fields long enough to take its picture. A few weeks later, Congress canceled the SSC. A few weeks after that, the top quark had its first snapshot taken at Chicago's Fermi labs. Then, a Texas entrepreneur proclaimed the $4 billion 10-mile hole in the ground created for the SSC an ideal spot for growing mushrooms. Boeing and Lockheed have just teamed up to work on Space Shuttle II. What did Space Shuttle I accomplish to justify the next multibillion dollar investment? Certainly, it launched many satellites, but they could disposable rockets. Indeed, if the American taxpayer had not been forced to subsidize those shuttle satellite launches (wiping out any possible competition that would have had to pay full cost), there might now be a viable private American corporation capable of launching satellites--a boon to the entrepreneurs waiting in line for years for a satellite launch. NASA has run out of useful work for the shuttle, let alone its successor. So we are bombarded by reports of German and Russian astronauts using the Canadian robot arm to perform ecology experiments. The large P.R. efforts that form in step 5 of all government megascience endeavors have learned that spreading the pork (step 4) now must be both an international and a politically correct endeavor. Some shuttle experiments--at a cost of about $500 million each--are simply ludicrous. Who cares or will ever care if spiders spin their webs differently in zero gravity? And technology con men are having a field day. One University of Houston professor convinced NASA to spend $2.5 billion on five shuttle flights to make space-grown gallium arsenide (GaAs) semiconductor wafers, the starting material for GaAs computer chips. The flight produced five wafers at a cost of about $100 million each. The promise is that in the near- perfect vacuum of space, the shuttle will produce GaAs semiconductor wafers nearly perfect in crystal structure. Eventually, the space-grown wafer cost is projected to drop to $10,000 per wafer. I am a member of the board of directors of the largest GaAs chip maker in the United States. Here are the facts: (1) Current terrestrial GaAs wafers cost $500. (2) The hypothesized improvement in the crystal structure of space-grown wafers is irrelevant, since the GaAs chip manufacturing process destroys and rebuilds the crystal as part of the process. (3) All GaAs companies would go out of business if their wafers cost $10,000 each. The basic problem with megaprogram funding is that particle physicists, space scientists, and big-company technology experts can have their way with a lay Congress that barely comprehends the complex technologies it is funding. And even that minimal comprehension comes only when huge sums are expended on ever-increasing congressional staffs. After eliminating the big-science megaprograms, Congress should attack the technology subsidies that Secretary of Labor Rober Reich reasonably calls ``corporate welfare''. The corporate subsidy most often touted as a success by the Clinton administration (yes, they speak on both sides of the issue) is Sematech, the Austin-based semiconductor research facility that has been given $1 billion in two five-year grants so far. A reasonably well-run organization, Sematech recently announced it would not seek a third $500-million grant. (Of course, the original Sematech promise was that it would not come back to Congress the second time.) The Clinton administration believes Sematech should be replicated in other industries. But its record is not one that warrants replication: Sematech has as members only 12 of America's 200 semiconductor companies. Two of Sematech's original 14 members quit because even with their dues halved by government subsidy they could not justify the investment. The big companies that control Sematech's board designed the consortium's dues structure to prevent small, entrepreneurial companies from joining. A $20-million chip company that may someday be the next Intel must pay 5 percent of revenue, while Intel itself pays only 0.15 percent of its revenue--a 33-to-1 ratio, which is the primary reason so few companies joined Sematech originally. Of course, Intel, which makes over $1 billion a quarter in pre-tax profits, needs the subsidy a lot less than the small companies that were excluded. But the political system provides the opposite results: Only big companies can muster the lobbying resources to convince Congress to subsidize them. And why would they share the pork with the upstarts? Sematech used its government subsidy to attack directly the other 100-plus American chip companies that were not Sematech members. After the checks were signed and the TV lights turned off, Sematech began granting funds to companies that make the critical equipment for the production of computer chips--in return for contracts to hold back the most advanced equipment from all but Sematech members for up to one year. (The deals, which Sematech denied repeatedly, were discovered during a law-suit.) It is no wonder that Sematech insisted on and received antitrust immunity as part of its funding legislation. If Sematech's silicon-chip subsidy represents the Clinton/ Gore model for government subsidies, it's up to the new Republican Congress to stop its replication. Let's not copy a system that allows well-heeled corporations to use their lobbying clout to entrench themselves with taxpayer subsidies, to the detriment of new companies with new ideals. The flow of bright, well-educated technologists into industry is much more important to American high-tech businesses than are subsidies to prop up ailing giants. And by cutting out science megaprograms and corporate technology subsidies, the new Congress can both cut the federal budget and free up funds to increase university research funding. Many Silicon Valley venture capitalists--no friends of big government--believe that the defunct DARPA (Defense Advanced Research Projects Agency) was one of the most effective government technology programs. They credit it with funding such winning pre-venture capital investments as the UNIX computer operating system work done by Sun Microsystems founder Bill Joy. DARPA funded my doctoral studies on transistor physics at Stanford. The high-performance chips I worked on may or may not have improved national defense, but I became one of the hundreds of DARPA-funded Ph.D.s who flooded into Silicon Valley from Stanford and Berkeley. What caused an unlikely agency like DARPA to provide decent return on government investment? DARPA conducted classified military research, which kept Congress on a need-to-know basis. Thus DARPA projects avoided having to spread the pork or to hire a P.R. staff to maintain viability. DARPA contracts were awarded by competent technical experts on a merit basis without much political consideration. DARPA also had a ``customer,'' the Pentagon, that had at least a long-run interest in the usefulness of what it funded. DARPA tended to fund the large number of small programs, rather than wasteful megaprojects. The agency was on the right side of the economic tradeoff that demands the sacrifice of 1,000 chances to fund the next Bill Joy/Sun Microsystems in order to fund one superconducting supercollider. Unfortunately, today's ARPA, the non-defense version of the old DARPA, is drifting back into politics. Members of Congress fantasize about ``dual use'' (military and commercial) technology, with the hope of picking losers and winners, the latter preferably in their districts. There are debates about where the ``retraining'' funds should be spent when military programs are shut down. Some of this is inevitable--ARPA's mission is hazier and more politicized that DARPA's. But the agency's best chance for success is if Congress leaves it alone, allowing it to set technical priorities and give out thousands of small grants to universities based only on a peer-review meritocracy. The new Congress has an opportunity to shrink the federal government and simultaneously help America's technology industries. It involves getting politics out of the laboratory and supporting education on a non-partisan, merit basis.

Mr. STARK

Mr. STARK. Mr. Speaker, I ask unanimous consent to remove my name as a cosponsor of H.R. 390.

Mr. STARK

Mr. STARK. Mr. Chairman, the Personal Responsibility Act is a disheartening, empty charade. It does very little to foster personal economic independence and virtually nothing to reform a welfare system that is in serious need of repair. The Republican bill simply passes the buck to the States. We should call this legislation the Government Responsibility Abdication Act, because all this bill does is to drop the responsibilities of the Federal Government and to push poor people off a cliff. By drastically reducing some benefits and eliminating others, this legislation creates a gaping hole in the safety net we provide for our neediest citizens. The Personal Responsibility Act misses the major point that any welfare reform should address--work. My Republican colleagues claim that they make people work under their bill. They claim that States are required to have 50 percent of one-parent welfare families and 90 percent of two-parent families in work programs by 1998. But what they do not tell us is that caseload reductions count toward this work requirement. So States can simply do nothing for 2 years, cut families off, and claim that they have put people to work. That is weak on work and tough on kids. Perhaps the cruelest and most disappointing aspect of this legislation is that it actually punishes those children who, through no fault of their own, are born poor. The bill punishes a child--for his entire childhood--for the sin of being born to a family on welfare. A child is also punished under this bill if he or she happens to be born to a young parent out-of-wedlock. Although I believe we should do everything reasonable to discourage teenagers from having out of wedlock children, this bill is not reasonable. It denies cash benefits to teenage mothers at a time when both the mother and child need support most. There is no evidence to suggest that teenagers get pregnant in order to collect welfare or that families on welfare have more children in order to collect more welfare benefits. The most direct and sensible way to decrease out-of-wedlock pregnancies, and all unintended pregnancies, is to make sure that family planning services are available to all who want them. But the welfare bill does nothing to make voluntarily family planning more available or accessible. Instead of offering our children a helping hand, this legislation introduces them to the harshest realities of life before they are able or prepared to cope. Reform of the welfare system should concentrate on healing families, not tearing them apart. dignity and hope is replaced with desperation and anger. This bill promotes a climate of social unrest and violence. The Personal Responsibility Act does what a responsible government should never do: it takes a difficult problem and makes it worse. There is no doubt that our current welfare system needs reform. But the Republican bill replaces a cruel system with a mean-spirited system. Welfare reform should not punish deserving residents and innocent children and must not take away the last vestiges of assistance that our Government provides.

Mr. STARK

Mr. STARK. Mr. Speaker, the following list of physician self-referral studies highlights the urgent need to uphold self-referral laws. Greedy physicians, interested more in personal gain than in their patient's welfare, have mounted an effort to repeal these laws. Physician self-referral is one of the most significant cost drivers in American medicine. According to some experts, billions of dollars are wasted each year on referrals motivated by physicians' financial gains and not strictly by their patients' medical needs. The following studies represent just some of the evidence that demonstrates when physicians are in a self-referring situation, they order more tests and charge more money for services than non-self-referring physicians. The evidence is convincing--patients need protection. [From the Department of Health and Human Services] Self-Referral Studies A. Financial Arrangements Between Physicians and Health Care Businesses: Office of Inspector General--OAI-12-88-01410 (May 1989) In 1989, the Office of Inspector General (OIG) issued a study on physician ownership and compensation from entities to which they make referrals. The study found that patients of referring physicians who own or invest in independent clinical laboratories received 45 percent more clinical laboratory services than all Medicare patients in general, regardless of place of service. OIG also concluded that patients of physicians known to be owners or investors in independent physiological laboratories use 13 percent more physiological testing services than all Medicare patients in general. Finally, while OIG found significant variation on a State by State basis, OIG concluded that patients of physicians known to be owners or investors in durable medical equipment (DME) suppliers use no more DME service than all Medicare patients in general. B. Physicians Responses to Financial Incentives--Evidence from a For-Profit Ambulatory Care Center; Hemenway D, Killen A, Cashman SB, Parks CL, Bicknell WJ: New England Journal of Medicine, 1990:322;1059-1063 Health Stop, a chain of for-profit ambulatory care centers, changed its compensation system from a flat hourly wage to a system where doctors could earn bonuses that varied depending upon the gross income they generated individually. A comparison of the practice patterns of fifteen doctors before and after the change revealed that the physicians increased the number of laboratory tests performed per patient visit by 23 percent and the number of x-ray films per visit by 16 percent. The total charges per month, adjusted for inflation, grew 20 percent, largely due to an increase in the number of patient visits per month. The authors concluded that substantial monetary incentives based on individual performance may induce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives. C. Frequency and Costs of Diagnostic Imaging in Office Practice--A Comparison of Self-Referring and Radiologist- Referring Physicians; Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noehter M. New England Journal of Medicine, 1990:322;1604-1608 This study compared the frequency and costs of the use diagnostic imaging for four clinical presentations (acute upper respiratory symptoms, pregnancy, low back pain, or (in men) difficulty in urinating) as performed by physicians who used imaging equipment in their offices (self-referring) and as ordered by physicians who always referred patients to radiologists (radiologist-referring). The authors concluded that self-referring physicians use imaging examinations at least four times more often than radiologist-referring physicians and that charges are usually higher when the imaging is done by the self-referring physicians. Those differences could not be attributed to differences in the mix of patients, the specialties of the physicians or the complexity of performed. D. Joint Ventures Among Health Care Providers in Florida: State of Florida Cost Containment Board (September 1991) This study analyzed the effect of joint venture arrangements (defined as any ownership, investment interest or compensation arrangement between persons providing health care) on access, costs, charges, utilization, and quality. The results indicated that problems in one or more of these areas existed in the following types of services: (1) clinical laboratory services; (2) diagnostic imaging services; and (3) physical therapy services-- rehabilitation centers. The study concluded that there could be problems or that the results did not allow clear-- conclusions with respect to the following health care services; (1) ambulatory surgical centers; (2) durable medical equipment suppliers; (3) home health agencies; and (4) radiation therapy centers. The study revealed no effect on access, costs, charges, utilization, or quality of health care services for; (1) acute care hospitals; and (2) nursing homes. E. New Evidence of the Prevalence and Scope of Physician Joint Ventures; Mitchell JM, Scott E: Journal of the American Medical Association, 1992:268:80-84 This report examines the prevalence and scope of physician joint ventures in Florida based on data collected under a legislative mandate. The results indicate that physician ownership of health career businesses providing diagnostic testing or other ancillary services is common in Florida. While the study is based on a survey of health care businesses in Florida, it is at least indicative that such arrangements are likely to occur elsewhere. The study found that at least 40 percent of Florida physicians involved in direct patient care have an investment interest in a health care business to which they may refer their patients for services; over 91 percent of the physician owners are concentrated in specialities that may refer patients for services. About 40 percent of the physician investors have a financial interest in diagnostic imaging centers. These estimates indicate that the proportion of referring physicians involved in direct patient care who participate in joint ventures is much higher than previous estimates suggest. F. Physicians' Utilization and Charges for Outpatient Diagnostic Imaging in a Medicare Population; Hillman BJ, Olson GT, Griffith PE, Sunshine JH, Joseph CA, Kennedy SD, Nelson WR, Bernhardt LB: Journal of the American Medical Association, 1992:268:2050-2054 This study extends and confirms the previous research discussed in section C, above, by focusing on a broader range of clinical presentations (ten common clinical presentations were included in this study); a mostly elderly, retired population (a patient population that is of particular interest with respect to Medicare reimbursement); and the inclusion of higher-technology imaging examinations. The study concluded that physicians who own imaging technology employ diagnostic imaging in the evaluation of their patients significantly more often and as a result, generate 1.6 to 6.2 times higher average imaging charges per episode of medical care than do physicians who refer imaging examination to radiologists. G. Physician Ownership of Physical Therapy Services; Effects on Charges, Utilization, Profits, and Service Characteristics; Mitchell JM, Scott E: Journal of the American Medical Association, 1992:268:2055-2059 Using information obtained under a legislative mandate in Florida, the authors evaluated the effects of physician ownership of freestanding physical therapy and rehabilitation facilities (joint venture facilities) on utilization, charges, profits, and service characteristics. The Study found that visits per patient were 39 to 45 percent higher in facilities owned by referring physicians and that both gross and net revenue per patient were 30 to 40 percent higher in such facilities. Percent operating income and percent markup were significantly higher in joint venture physical therapy and rehabilitation facilities. The study concluded that licensed physical therapists and licensed therapist assistants employed in a non-joint venture facilities spend about 60 percent more time per visit treating patients than those licensed workers in joint venture facilities. Finally, the study found that joint ventures also generate more of their revenues from patients with well-paying insurance. H. Consequences of Physicians' Ownership of Health Care Facilities--Joint Ventures in Radiation Therapy; Mitchell JM, Sunshine, IH; New England Journal of Medicine 1992; 327; 1497-1501 This study examined the effects of the ownership of freestanding radiation therapy centers by referring physicians who do not directly provide services (``joint ventures'') by comparing data from Florida (where 44 percent of such centers were joint ventures during the period of the study) to data from elsewhere (where only 7 percent of such centers were joint ventures). The analysis shows that the joint ventures in Florida provide less access to poorly served populations (rural counties and inner-cities) than non-joint venture facilities. The frequency and costs of radiation therapy treatments at free-standing centers in Florida were 40 to 60 percent higher than in non-joint venture facilities; there was no below-average use of radiation therapy at hospitals or higher cancer rates to explain the higher use or higher costs. Some indicators (amount of time spent by radiation physicians with patients and mortality among patients with cancer) show that joint ventures cause either no improvement in quality or a decline. I. Increased Costs and Rates of Use in the California Workers' Compensation System as a Result of Self-Referral by Physicians; Swedlow A, Johnson G, Smithline N, Milstein A; New England Journal of Medicine, 1992;327;1502-1506 The authors analyzed the effects of physician self-referral on three high-cost medical services covered under California's workers compensation physical therapy, psychiatric evaluation and magnetic resonance imaging (MRI). They compared the patterns of physicians who referred patients to facilities of which they were owners (self- referral group) to patterns of physicians who referred patients to independent facilities (independent-referral group). The study found that physical therapy was initiated 2.3 times more often by the self-referral group than those in the independent-referral group (which more than offset the slight decrease in cost per case). The mean cost of psychiatric evaluation services was significantly higher in the self-referral group (psychometric testing, 34 percent higher, psychiatric evaluation reports, 22 percent higher) and the total cost per case of psychiatric evaluation services was 26 percent higher in the self-referral group than in the independent-referral group. Finally, the study concluded that of all the MRI scans requested by the self- referring physicians, 38 percent were found to be medically inappropriate, as compared to 28 percent of those requested by physicians in the independent-referral group. There were no significant difference in the cost per case between the two groups. J. Medicare: Referrals to Physician-Owned Imaging Facilities Warrant HCFA's Scrutiny (GAO Report No. B-253835; October 1994) The U.S. General Accounting Office (GAO) issued a report regarding: (1) referrals by physicians with a financial interest in joint-venture imaging centers; and (2) referrals for imaging provided within the referring physicians' practice settings. The analyses are based on information collected by researchers in Florida for the Florida Health Care Cost Containment Board and include information on 1990 Medicare claims for imaging services ordered by Florida physicians. GAO analyzed approximately 1.3 million imaging services performed at facilities outside the ordering physicians' practice settings and approximately 1.2 million imaging services provided within the ordering physicians' practice settings. These results are significant because they are based on a large-scale analysis of physician referral practices. GAO found that physician owners of Florida diagnostic imaging facilities had higher referral rates than nonowners for almost all types of imaging services. The differences in referral rates were greatest for costly, high technology imaging services; physician owners ordered 54 percent more MRI scans, 27 percent more computed tomography (CT) scans, 37 percent more nuclear medicine scans, 27 percent more echocardiograms, 22 percent more ultrasound services, and 22 percent more complex X rays. Referral rates for simple X rays were comparable for owners and nonowners. In addition, while referral practices among specialities differed, physician owners in most specialties had higher referral rates than nonowners in the same specialty. GAO also compared the imaging rates of physicians who have in-practice imaging patterns (i.e., more than 50 percent of the imaging services they ordered were provided within their practice affiliations) with physicians with referral imaging patterns (i.e., more than 50 percent of the imaging services they ordered were provided at facilities outside their practice affiliations). GAO found that physician with in- practice imaging patterns had significantly higher imaging rates than those with referral imaging patterns--the imaging rates were about 3 times higher for MRI scans; about 2 times higher for CT scans; 4.5 to 5.1 times higher for ultrasound, echocardiography, and diagnostic nuclear medicine imaging, and about 2 times higher for complex and simple X rays.

Mr. STARK

Mr. STARK. Mr. Speaker, I stand before you today to recognize a partnership which is making a significant difference in northern California. Fannie Mae, the Golden State Warriors and their owner, Christopher Cohan, have joined in an effort to alleviate some of our community's housing needs. About a year ago, Fannie Mae and the Golden State Warriors basketball team created the Home Team Fund--a program which assists low-income families and first-time home buyers. In this short period, they have conducted an extensive consumer outreach effort, raised funds for actual construction, and have even pounded nails themselves during the construction of two new homes. According to Fannie Mae, a lack of knowledge and a fear of the home- buying process prevent many qualified people from taking that first step to buying a home. To tackle this problem or should I say slam- dunk, Fannie Mae and the Warriors sponsored a free Home-Buying Fair at the Oakland Coliseum in April 1994. Local lenders, real estate professionals, counseling agencies, and housing nonprofits were there to encourage and educate those who thought owning a home was out of their reach. More than 5,000 people attended this one day fair to learn about how to buy a home. The partnership has also raised funds which provide grants for actual construction. In fact, a portion of the gate receipts from this evening's game, and proceeds from a sports memorabilia auction prior to the game, will be contributed to this fund. Their voluntarism has also included hands-on efforts. In a project managed by East Bay Habitat for Humanity, Warrior players, coaches and staff participated in the actual construction of two new homes in East Oakland. This year, two additional homes will be built and will be sold to families who contribute ``sweat'' equity to the project. Mr. Speaker, I hope you and my colleagues will join me in congratulating this unconventional, but successful housing partnership. Mr. Cohan and the Warriors' altruistic concern for its community is deserving of special recognition, and we should encourage more organizations to enter into these sort of joint ventures.

Mr. STARK

Mr. STARK. Mr. Speaker, I always thought that the 1729 ``Modest Proposal'' essay by Jonathan Swift about how to solve the terrible homeless and hunger problems in Ireland was one of the most devastating satires ever written. The new Republican welfare bill, however, may cause Republican Governors to seriously consider Swift's proposal. By ending cash assistance as an entitlement and drastically cutting the funds available, the Republican bill guarantees that in the next recession, there will be millions of homeless and hungry children in America. To avoid the embarrassment of the failure of their social theories, the Republican Governors may adopt Swift's Modest Proposal and resort to eating the evidence. The following update of Swift's essay was found in the Ways and Means hearing room during the committee's mark-up of the welfare deform legislation. It appears to be 99 percent Swift and 1 percent update. A Modest Proposal for Preventing the Children of Poor People in America From Being a Burden to Their Parents or Country, and for Making Them Beneficial to the Public (An up-date of a 1729 proposal by an early Cato Institute thinker, Jonathan Swift, to be added to the Republican Welfare Reform bill) It is a melancholy object to those who walk through this great Capital, or travel in the country, when they see at red lights, in the streets, and on the steam grates herds of beggars, followed by three, four, or six children, all in rags, and importuning every passenger for Metro fare. These families, instead of being able to work for their honest livelihood, are forced to employ all their time in washing car windows and begging sustenance for their helpless infants, who, as they grow up, turn thieves for want of work. I think it is agreed by all parties that this prodigious number of children is a very great additional grievance; and therefore whoever could find a fair, cheap, and easy method of making these children sound an useful members of the Republic would deserve so well of the public as to have his statue set up (perhaps in a beggar-free Lafayette Park) as a preserver of the nation. But my intention is very far from being confined to provide only for the children of professed beggars; it is of a much greater extent, and shall take in the whole number of infants at a certain age who are born of parents who live under duress, to wit: of minimum wage workers, temps, contract workers, legal aliens, illegal aliens, and farm workers. As best can be computed by the Bureau of Labor Statistics, a child just dropped from its dam may be supported by her milk for a solar year with little other nourishment, at most not above the value of $20, which the mother may certainly get, or the value in scraps, by her lawful occupation of begging, and it is exactly at one year old that I propose to provide for them, in such a manner as, instead of being a charge upon their parents, or the local charities, or wanting food and Levi's and sneakers the rest of their lives, they shall, on the contrary, contribute to the feeding and partly to the clothing of many thousands. There is likewise another great advantage in my scheme, that it will prevent those voluntary abortions, and that horrid practice of women murdering their bastard children, alas, too frequent among us, sacrificing the poor innocent babes, I doubt, more to avoid the expense than the shame, which would move tears and pity in the most savage and inhuman beast. The number of souls in America being about 270 million and the number of babies born out of wedlock and without identity of father about 277,000 a year, the question therefore is, how this number shall be reared, and provided for, which in the current national mood seems utterly impossible by all the old socialist methods, for we can neither employ them in handicraft or agriculture; they can very seldom pick up a livelihood by stealing until they arrive at six years old, except where they are of towardly parts, although I confess they learn the rudiments much earlier, during which time they can however be properly looked upon only as probationers. I am assured by our apparel sweatshop owners that a boy or a girl before twelve years old, is no salable commodity, and even when they come to this age, they will not yield above $300, which cannot turn to a profit either their parents or the Nation, the charge of burgers, French fries, and bluejeans having been at least four times that value. I shall now therefore humbly propose my own thoughts, which I hope will not be liable to the least objection. I have been assured by a very knowing Heritage Foundation scholar of my acquaintance, that a young healthy child well nursed is at a year old a most delicious, nourishing and wholesome food, whether stewed, roasted, baked, or boiled, and I make no doubt that it will equally serve in a fricassee, or a ragout. I do therefore humbly offer it to the Ways and Means Committee's consideration, that of every 277,000 children already computed, twenty thousand may be reserved for breed, whereof only one fifth part to be males, which is more than we allow to sheep, cattle, or swine, and my reason is that these children are seldom the fruits of marriage, a circumstance not much regarded by our savages, therefore one male will be sufficient to serve four females. That the remaining quarter million or so may at a year old be offered in sale to the persons of quality, and fortune, always advising the mother to let them suck plentifully in the last month, so as to render them plump, and fat for a good table. A child will make two dishes at an entertainment for friends, and when the family dines alone, the fore or hind quarter will make a reasonable dish, and seasoned with a little pepper or salsa will be very good boiled on the fourth day, especially in February. I have reckoned upon a medium, that a child just born will weigh ten pounds, and in a solar year if tolerably nursed increaseth to twenty-eight pounds. I grant this food will be somewhat dear, and therefore very proper for the owners of plants which have moved to Mexico, who, as they have already devoured most of the parents, seem to have the best title to the children. I have already computed the charge of nursing a beggar's child (in which list I reckon, as said, various aliens, minimum wager laborers, tenant farmers, etc.) to be about $20 per annum, rags included, and I believe no gentleman would repine to give $6 per pound for the carcass of a good fat child, which, as I have said, will make four dishes of excellent nutritive meat, when he hath only some particular friend or his own family to dine with him. Thus will the Merger and Acquisition dealers of the nation learn to grow popular among the working population for their purchase of these repasts, and the mother will have about $150 net profit, and be fit for work until she produces another child. Among the merits of this proposal I offer the following: Whereas the maintenance of 250,000 children from year one upwards cannot be computed at less than $1,000 a piece per annum, the nation's stock will be thereby increased a quarter billion dollars per year, compounded year by year, besides the profit of a new dish, introduced to the tables of all gentleman of fortune who have any refinement of taste, and the money will circulate among ourselves, the goods being entirely of our own growth and manufacture and not from some pesky import. Whereas the constant breeders, besides the gain of $150 per annum by the sale of their children, will be rid of the charge of maintaining them after the first year. Finally, this Modest Proposal would be a great inducement to marriage, which all wise nations have either encouraged by rewards, or enforced by laws and penalties. It would increase the care and tenderness of mothers towards their children, when they were sure of a settlement for life, to the poor babes, provided in some sort by the public to should soon see an honest emulation among the married women, which of them could bring the fattest child to the market. Men would become as fond of their wives, during the time of their pregnancy, as they are now of their mares in foal, their cows in calf, or sows when they are ready to farrow, nor offer to beat or kick them (as it is too frequent a practice) for fear of a miscarriage.

Mr. STARK

Mr. STARK. Mr. Speaker, there are approximately 200,000 Medicare beneficiaries in the Endstage Renal Disease [ESRD] Program, initially established by the Social Security Act Sec. 1881. This debilitating disease costs approximately $10 billion per year translating to a cost of $51,000 per patient.\1\ Dialysis treatment for the ESRD patient is in essence an artificial kidney, and while there have been multitudes of research papers and numerous conferences addressing the issue of standards for dialysis treatment, the development of these standards has been a slow process. There is presently a need for quality assessment and continuous quality improvement (QA & CQI) within dialysis facilities, reformation of reimbursement schedules, improved data collection, and the introduction of industry-wide treatment standards for the benefit of the patient as well as the providers. Footnotes at end of article. In recent years, numerous studies have shown relatively unexplained and dramatic differences in survival rates between kidney dialysis facilities. While it is often explained that facilities with higher mortality rates also treat sicker patients, this only explains part of the story. Mortality rates between facilities range from 0 to 43 deaths per 100 dialysis years, which means that there are other causes of death attributable to the treatment centers that cannot be explained by how sick their patients are.\2\ To be blunt, some facilities are allowing their patients to die prematurely and needlessly. I believe that there is now a relative consensus among kidney disease experts that if certain quality standards are met during the course of dialysis treatment, a patient has an improved chance of prolonged survival. Mortality rates for dialysis patients remain consistently greater than 20 percent.\3\,\4\ Similarly, renal failure has a significant impact on the life expectancies of its victims. According to a recent NIH Consensus Panel, at 49 years of age, the average life expectancy of a patient with ESRD is 7 years, compared with 30 years for an age- matched person without ESRD.\5\ The mortality rates for patients with ESRD are increased for men, whites, elderly, diabetics, and patients with impaired functional status and malnutrition.2,3,6-8 Survival is further complicated by the changes within the ESRD patient population and the growing list of comorbidities that contribute to their worsened state of health. Although differences between patient subgroups can result in variable risk factors for death, it seems that dialysis treatment times consistently effect the mortality rates of renal failure patients. Dialysis functions as an artificial kidney by removing waste products from the blood, and the standard for dialysis should be expressed in terms of the formula KT/V. This formula has been offered as the most effective measurement in determining the adequacy of hemodialysis treatment. Most authors agree that the KT/V must be at least 1.0 or greater to achieve an adequate dose of dialysis, and many have concluded that levels as high as 1.2-1.4 are necessary to reduce mortality. Therefore, I am introducing a bill today to require the Secretary of HHS to deny payment to a facility after January 1, 1997, if a majority of its patients do not receive a dialysis treatment which sufficiently cleans the blood. Hemodialysis must be supplied to achieve a delivered KT/V of 1.2. This bill will also establish contingencies whereby dialysis facilities could calculate treatment effectiveness using the urea reduction ratio [URR] instead of the KT/V. In simple terms, the URR measures the percentage of waste products cleansed from the blood over the course of a single dialysis treatment. The standards would be set to achieve a delivered URR of 65 percent. Although the URR does not have the accuracy the need for computer software and can provide a useful verification of treatment effectiveness. It is understood that there are other factors affecting the outcome of patients on dialysis; however, dialysis has become quantifiable and, therefore, should be utilized to effectively realize treatment goals. Putting this in layman's terms, it is possible to measure the amount of dialysis a patient will receive by knowing the duration of treatment, the amount of waste products in the blood, and the quantity of blood that the dialysis filter will clear of those waste products during treatment. In essence, the longer a patient remains on a dialysis machine, the more likely they are to achieve the 1.2 figure. It is appalling to think that some facilities would cut the amount of time on the dialysis machine in order to save money. Quality dialysis facilities have shown us that they can make money and still provide adequate time on the machine. Furthermore, statistical studies have demonstrated that increased time translates into less death. I believe there is enough medical consensus on this point that it would be improper for Medicare to continue to pay for facilities that do not provide adequate levels of dialysis as measured by the KT/V value. That is what my bill seeks to do: Force those facilities which are not providing sufficient dialysis to improve their level of care in accordance with a set of industry-wide standards, and ultimately stop the premature death of their patients. Many studies have shown the correlation between increased treatment time and decreased mortality rates. 7,9-14 However, it has been argued that the combination of falling real-dollar reimbursement rates and increases in the required bundle of services have caused not only a decline in the amount of dialysis being delivered but also a reduction in the ability of dialysis centers to provide adjunct resources such as dietary counseling, social work management, mental health information, and vocational rehabilitation. As Congress considers this legislation, it also needs to examine and address this whole range of issues impacting on the lives of dialysis patients. Medical science is continually evolving, of course, and future information may provide us with a better measure of dialysis or show us that 1.2 is not the right number to strive for. Therefore, my bill authorizes the Secretary to adjust the KT/V value or substitute a different formula if a report is sent to Congress explaining the wisdom of such a change. My bill also addresses the issue of monitoring dialysis facilities in order to assess their compliance with the above standards. Once the progression to chronic renal failure has occurred, the main goals of the medical community should be to maintain and improve, if possible, the quality of life of the end-stage renal disease patient. Treatment plans should focus on prescription and delivery of adequate dialysis, attention to the social and psychological factors that influence survival and functional outcome of hemodialysis patients, provision of dietary counseling and management, assessment and reduction of malnutrition, control of hypertension, strict management of diabetes, maintaining vascular access, and provision of vocational rehabilitation. In closing, Mr. Speaker, I urge the renal community to evaluate the need for reform within the dialysis industry to reduce the untimely deaths of so many patients with kidney failure. references \1\VanValkenburgh D and Snyder S. Challenges and barriers to managing quality in an end-stage renal disease facility. ``American Journal of Kidney Diseases'' 1994;24(2):337-345. \2\McClellan W and Soucie M. Facility mortality rates for new end-stage renal disease patients: Implications for quality improvement. ``American Journal of Kidney Diseases'' 1994;24(2):280-289. \3\Levinsky N and Mesler D. Measuring, managing, and improving the quality of end-stage renal disease care. ``American Journal of Kidney Diseases'' 1994;24(2):235-246. \4\Lowrie E. Chronic dialysis treatment: Clinical outcome and related process of care. ``American Journal of Kidney Diseases'' 1994;24(2):255-266. \5\Consensus Development Conference Panel. Morbidity and mortality of renal dialysis: An NIH Consensus Conference statement. ``Annals of Internal Medicine'' 1994;121(1):62-70. \6\Levin N. Adequacy of dialysis. ``American Journal of Kidney Diseases'' 1994;24(2):308-315. \7\Lowrie EG and Lew NL. Death risk in hemodialysis patients: The predictive value of commonly measured variables and an evaluation of death rate differences between facilities. ``American Journal of Kidney Diseases'' 1990;15:458-482. \8\Owen WF, et al. The urea reduction ratio and serum ablumin concentration as predictors of mortality in patients undergoing hemodialysis. ``NEJM'' 1993;329:1001-1006. \9\Collins AJ, et al. Urea index and other predictors of hemodialysis patient survival. ``American Journal of Kidney Diseases'' 1994;23:272-282. \10\Held PJ, Levin NW, Bovbjerg JD, Pauly MV, and Diamond LH. Mortality and duration of hemodialysis treatment. ``JAMA'' 1992;265(7):871-875. \11\Hakim RM, et al. Adequacy of hemodialysis. ``American Journal of Kidney Diseases'' 1992;20:107-124. \12\Blagg C. The US Renal Data System and the Case-mix Severity Study. ``American Journal of Kidney Diseases'' 1993;21(1):106-108. \13\Hakim RM, Breyer J, Ismail N, Schulman G. Effects of dose of dialysis on morbidity and mortality. ``American Journal of Kidney Diseases'' 1994;23(5):661-669. \14\Parker T, Husni L, Huang W. Survival of hemodialysis patients in the United States is improved with a greater quantity of dialysis. ``American Journal of Kidney Diseases'' 1994;23(5):670-680.

Mr. STARK

Mr. STARK. Mr. Speaker, I would like to address this issue of kidney disease and its progression to end-stage renal disease [ESRD]. The Social Security Act section 1881 has established the ESRD Program as part of Medicare in order to provide treatment for patients with renal failure. Currently there are about 200,000 beneficiaries of the ESRD Program. The average ESRD patient is now costing the health care system--primarily Medicare--an estimated $51,000 per year, or $4,250 per month. The number of patients entering the ESRD Program is increasing, and these patients are sicker than in the past. Obviously, delaying the onset of kidney failure could greatly improve a patient's quality of life and money. An ESRD patient can choose either transplantation or dialysis. Without these measures, kidney failure is lethal. Dialysis, a mechanical cleansing of the blood, is disruptive to an individual's lifestyle and negatively impacts on one's quality of life. The work force is diminished daily as patients learn that they must begin dialysis treatment. In fact a recent study found that only 11 percent of the interviewed patients were employed. If we focused our energies on delaying the day which a patient must accept the burden of dialysis, we could realize a cost savings and improve the patient's quality of life. As a result of the evidence before us, I am today introducing legislation to require the Medicare agency to conduct a 3-year demonstration program to quantify the cost and benefits associated with identifying patients who are approaching renal failure, providing a range of services to them, and thus effectively delaying the onset of complete renal failure. The demonstration will attempt to determine whether the savings from a prevention program, including improvement in quality of life measurements and job retention, exceed the cost of the preventive services themselves. The prevention of progression to renal failure should be the primary focus when constructing treatment goals for patients with renal disease. While all the preventive measures that will consistently produce an increase in survival are as yet undetermined, there is a wealth of evidence that many patients can be effectively managed so as to delay the day that dialysis is needed to survive. I feel that the medical community knows enough about such preventive strategies and the patient populations that would most benefit from them to explore the idea of extending the Medicare ESRD benefit package to these patients prior to dialysis. A recent NIH consensus panel concluded that because comorbid factors affecting the outcome of renal disease are present prior to the onset of renal failure, patients should referred to a renal team for evaluation before dialysis begins. This team should consist of a physician, nurse, social worker, dietitian, and mental health professional and focus on the reduction in mortality and morbidity of the patient. There should be an interest in controlling hypertension and diabetes, reducing cardiovascular risk factors, correcting metabolic, endocrinologic, and hematologic abnormalities, treating underlying illnesses, evaluating and modifying psychological and social stressors, and setting nutritional parameters. More specific guidelines for the prevention of progression to renal failure that can be undertaken encompass the following: First, encouraging smoking cessation, reducing obesity, increasing aerobic exercise, reducing the intake of fat and cholesterol, correcting anemia, monitoring calcium and phosphorous; second, implementing the most recent American Diabetic Association guidelines for strict management of diabetes; third, reducing exposure to environmental toxins including analgesic abuse, lead poisoning, and other nephrotoxins; fourth, managing hypertension through prescription of angiotensin converting enzyme inhibitors and calcium channel blockers preferentially; fifth, regulating diet to maintain normal acid-base balance and intravascular fluid volume; and sixth, evaluating and correcting malnutrition. Diabetes is the No. 1 cause of renal failure in the United States. Approximately 25-35 percent of new ESRD patients have diabetes as the underlying etiology. Greater than 65 percent of all ESRD is due to diabetes and hypertension combined. The intensive management of both hypertension and diabetes has the benefit of reducing the time to the onset of dialysis. Although the progression to ESRD is rare in people with hypertension, there is the paradox of its continuing increase despite improvements in blood pressure control in the general population and reduction in mortality from other complications associated with hypertension. Cardiovascular mortality accounts for approximately 50 percent of deaths in patients receiving dialysis, highlighting the need for control of risk factors such as hypertension, smoking, anemia, obesity, and lipid abnormalities. Furthermore, the racial differences manifested in the increased risk of hypertension-related ESRD for blacks, and the excess risk of ESRD for low income, poorly educated blacks and whites must stimulate new evaluation of these problems. The correlation between lower socioeconomic status and ESRD has been examined, with several inter- related factors possibly playing a role, including: lack of appropriate access to health care, lack of a primary care physician, lack of insurance, and non-compliance with a treatment regimen. Further examination of the relationship between hypertension, renal disease, and the interrelated factors must be undertaken in order to develop and implement viable treatment regimens that will have lasting effects. The patients in the ESRD Program have not only suffered through the tremendous burden of kidney failure, but their quality of life is further worsened by factors that can be corrected. The medical community needs to identify patients with renal disease prior to the onset of renal failure in order to reduce the burden of dialysis, thereby allowing these patients to remain viable members of the work force. The benefits of weight loss, regulation of fat intake, and reduction of stress have all become commonplace in the layperson's repertoire of medical knowledge. Strict control of diabetes, hypertension, diet, and psychological stressors can also have a real benefit for patients with kidney disease in reducing the onset of renal failure, subsequently improving the quality of life, and ultimately retrieving some patients from the brink of dialysis.

Mr. STARK

Mr. STARK. Mr. Speaker, today, as we celebrate Black History Month, I would like to recognize 258 African-American World War II veterans who have wrongfully had to live with the shame of being mutineers. For over 50 years, some of these men have hidden their past, when it should be proudly and widely shared with the rest of our country. In 1944, when our Nation was at war with one of the world's most infamous racists--Adolph Hitler--almost all the men assigned to load munitions onto Liberty ships in this country were black. Upon their enlistment, many of the black naval recruits expected to be trained as sailors and go to sea, but instead, were assigned without proper training to the menial and dangerous work at the Port Chicago Naval Weapons Station in the San Francisco Bay area. During their stint at Port Chicago black sailors were quickly introduced to the discriminatory attitude of the Navy. Then on July 17, at 10:18 p.m., two explosions with a force equal to the bomb dropped on Hiroshima nearly leveled the area. Two military cargo ships loaded with ammunition and the entire Port Chicago waterfront were vaporized by the blast and literally disappeared from the face of the earth. The blast left 320 dead, of which 202 were black. After a relatively short investigation, the cause of the explosion was never identified. Shortly afterward, another tragedy ensued. On August 9, after spending several weeks picking up the remains of their friends, the surviving black sailors were ordered to return to loading ammunition at Mare Island under the same unsafe conditions that sparked the explosion in July. Afraid, 258 of them refused to comply and were immediately imprisoned on a barge. Several days later, after being threatened with the death penalty, 208 of them agreed to return to work. The remaining 50 were charged--not with disobeying an order--but with mutiny, an act punishable by death. The court-martial proceedings were ``one of the worst frame-ups we have come across,'' wrote NAACP attorney Thurgood Marshall in his appeal on behalf of the men. The shame of these mutiny trials also aroused the passion and activism of First Lady Eleanor Roosevelt when she wrote a letter to the Secretary of the Navy asking for leniency in the sentencing of the men. Mrs. Roosevelt was one voice among many who joined in the campaign on behalf of the convicted Port Chicago sailors. Recent revelations discovered by Oakland, CA, author Robert Allen, Ph.D., fully exposed the racial segregation and bias in the Navy black sailors did not receive a fair trial because of their race. The court-martial convictions of these African-American sailors was not only a great injustice, but also an event in our country's history that should be duly recognized. Historians believe that the Port Chicago explosion and the following events helped speed the desegregation of the military by President Truman. As we well know, this action earned him a place in our history books as a great advocate of civil rights. However, the men who valiantly protested the conditions in Port Chicago, have had to live with the shame of being mutineers. In recent years, Congress initiated efforts to secure a review of these convictions based on new evidence that demonstrated significant racial prejudice in the trial proceedings. On January 7, 1994, the Navy refused to overturn the convictions following a review mandated by legislation approved by Congress. Although the Navy found that racial discrimination had existed, it decided there was no basis for overturning the convictions. More recently, Congressmen Ronald Dellums, George Miller, and myself have urged President Clinton to consider expunging their records. Many of these veterans and their families have lived with this unjust decision for many years. It is time for the United States to admit to this national disgrace and remove the stigma of dishonor from these brave men. I ask my colleagues to join me in recognizing the contribution of these civil rights leaders to our country.

Mr. STARK

Mr. STARK. Mr. Speaker, I demand a recorded vote.

Mr. STARK. I am opposed to the bill in its present form, Mr. Speaker.